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Anthem letters raise yellow flag on use of modifiers
e-Reports, March 18, 2013
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Several physician practices have contacted the ISMA about letters they received from Anthem through their contractor EquiClaim. The communication appears to target physicians identified as “billing E/M codes with modifier 25 significantly more often than other physicians within the same specialty.”

The letters indicate medical records might be requested to identify inaccurate coding and recover any overpayments. The claims data includes commercial and Medicare Advantage plans.

“To be proactive, practices need to confirm that they are using the modifier correctly and understand that Anthem, and perhaps other payers, is reviewing their claims for accurate payment,” said Sandy Miller, CCS-P, ISMA director of Practice Management. “If Anthem requests overpayments as a result of an audit and you believe you have used the modifiers correctly, the audit should be challenged.”

Practices might also consider an outside consultant’s assistance as it relates to the appeal and/or any education on use of this and other modifiers. In the meantime, the ISMA is contacting Anthem to determine if actual claims data could be provided with the letters, making the information more useful to physician practices.

“We are adding this topic to most of the speaker presentations at the Coding Symposium talks in April because modifiers are challenging for practices to bill correctly,” added Miller. “We also want Anthem to address the letters at our Commercial Payer Forum in June.”

Learn more about the Coding Symposium and the Commercial Payer Forum on the ISMA website.

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